What are the recommended treatment options for a patient with osteoarthritis?

Recommended Treatment Options for Osteoarthritis

All patients with osteoarthritis should begin with core non-pharmacological interventions—specifically regular exercise (land-based aerobic and/or resistance training), weight loss if BMI ≥25 kg/m², and self-management programs—before escalating to pharmacological treatments. 1, 2

Core Non-Pharmacological Interventions (First-Line for All Patients)

Exercise therapy is the foundation of OA management and should be implemented immediately:

• Land-based aerobic and/or resistance exercise is strongly recommended for all patients with knee, hip, and hand OA 1, 2
• Quadriceps strengthening exercises are particularly critical for knee OA 3
• Aquatic exercise should be offered to patients who cannot tolerate weight-bearing activities due to severe joint damage 2
• Exercise selection should be based on patient preferences and accessibility to maximize adherence 1, 2
• Benefits require ongoing, regular participation—not just short-term programs 1, 2

Weight management is equally critical:

• Weight loss is strongly recommended for all overweight or obese patients (BMI ≥25 kg/m²) with knee or hip OA 1, 2, 3
• Even modest weight reduction (5-10% of body weight) significantly improves symptoms and slows disease progression 2, 3
• Combined weight loss and exercise programs are more effective than either intervention alone 2

Additional non-pharmacological interventions with strong evidence:

• Self-efficacy and self-management programs help patients understand their condition and develop coping strategies 1, 2, 3
• Tai chi is strongly recommended as an effective exercise modality 1
• Cane use is strongly recommended to reduce joint loading and improve mobility 1, 2
• Tibiofemoral bracing is strongly recommended for appropriate patients to provide stability and decrease weight burden 1, 2, 3
• First CMC joint orthoses are strongly recommended for hand OA 1

Pharmacological Treatment Algorithm

After implementing core non-pharmacological interventions, escalate pharmacotherapy in the following order:

First-Line Pharmacological Options

Topical NSAIDs are the preferred initial pharmacological treatment:

• Topical NSAIDs (e.g., diclofenac gel) are strongly recommended for knee OA as first-line pharmacological therapy 1, 2, 3
• They provide local anti-inflammatory effects with minimal systemic side effects 2, 3
• Particularly appropriate for elderly patients or those with cardiovascular/gastrointestinal risk factors 3, 4

Oral NSAIDs when topical therapy is insufficient:

• Oral NSAIDs are strongly recommended for hand, knee, and hip OA when topical options provide inadequate relief 1, 2, 3
• Use the lowest effective dose for the shortest duration 4
• Mandatory proton pump inhibitor co-prescription for gastroprotection in all patients receiving oral NSAIDs 4
• For patients with GI risk factors, use a COX-2 selective inhibitor or combine a nonselective NSAID with a proton pump inhibitor 2
• Avoid oral NSAIDs entirely in patients with history of gastrointestinal bleeding or significant cardiovascular disease 2

Acetaminophen has limited utility:

• Acetaminophen (up to 4,000 mg/day) is conditionally recommended as initial therapy due to favorable safety profile 2
• However, it has substantially lower efficacy than NSAIDs 3, 5
• Many updated guidelines now question its role due to concerns about efficacy 5

Second-Line Pharmacological Options

Intra-articular corticosteroid injections for acute flares:

• Strongly recommended for knee and hip OA, particularly for acute pain relief with effusion 1, 2, 3
• Provide short-term pain relief lasting approximately 2-4 weeks on average, up to 3 months maximum 4, 6
• Can be repeated for moderate to severe pain flares, with up to 4 injections annually 4, 6
• Important caveat: Recent evidence suggests repeated corticosteroid injections may be associated with more MRI-assessed cartilage thickness loss than saline injections 6

Duloxetine for inadequate response to initial treatments:

• Conditionally recommended for patients with inadequate response to NSAIDs 1, 2, 3
• Start at 30 mg/day and increase to 60 mg/day 2

Tramadol as alternative analgesic:

• Conditionally recommended as an alternative analgesic 1, 4
• Use only for short-term management of severe pain due to risk of dependence 3

Conditional or Adjunctive Options

The following have conditional recommendations (weaker evidence):

• Topical capsaicin for knee OA 1, 3
• Acupuncture (conditional recommendation) 1
• Kinesiotaping (conditional recommendation) 1
• Thermal modalities (conditional recommendation) 1
• Cognitive behavioral therapy (conditional recommendation) 1

Treatments NOT Recommended

The following interventions should NOT be used:

• Rubefacients are not recommended 1
• Intra-articular hyaluronic acid injections are not recommended 1
• The American Academy of Orthopaedic Surgeons strongly recommends against routine use of hyaluronic acid due to inconsistent evidence, high number needed to treat, and inability to identify responders 4
• Hyaluronic acid should only be considered as a last resort after failure of all conservative treatments, and only in patients with mild radiographic disease and significant surgical risk factors 4
• Glucosamine and chondroitin are conditionally not recommended due to lack of evidence for efficacy 1, 2
• Long-term opioid use should be avoided as evidence does not support their use in OA management 2
• Platelet-rich plasma (PRP) is strongly recommended against due to lack of standardization and unclear benefit-to-risk ratio 4

Surgical Referral Criteria

Refer for joint replacement surgery when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life 1, 4
• Symptoms are refractory to comprehensive non-surgical treatment for 3-6 months 4
• Referral should be made before prolonged and established functional limitation develops 1, 4
• Patient-specific factors (age, sex, smoking, obesity, comorbidities) should NOT be barriers to referral 1

Arthroscopic procedures have limited indications:

• Arthroscopic lavage and debridement should NOT be routinely offered 1
• Only consider for knee OA with a clear history of mechanical locking—not for gelling, "giving way," or x-ray evidence of loose bodies 1

Common Pitfalls to Avoid

Critical errors in OA management:

• Do NOT skip core non-pharmacological treatments (exercise, weight loss, self-management)—these are as important as any medication 2, 3, 4
• Do NOT use hyaluronic acid as routine next step after failed steroid injections—this contradicts current evidence-based guidelines 4
• Do NOT forget gastroprotection when prescribing oral NSAIDs 4
• Do NOT delay surgical referral when conservative measures consistently fail for 3-6 months 4
• Do NOT rely on passive treatments without active exercise therapy 3
• Do NOT use long-term opioids for OA pain management 2, 3